CARC 35 Active

PR-35: Lifetime Benefit Maximum Reached

TL;DR

The patient is responsible for this adjustment amount. Verify the balance and collect from the patient.

Action
Collect from Patient
Who Pays
Patient
Appeal
Yes
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-35 Mean?

With PR (Patient Responsibility), the amount adjusted under CARC 35 is owed by the patient. The payer determined that this portion — related to lifetime benefit maximum reached — falls under the patient's financial obligation per their plan benefits.

CARC 35 indicates lifetime benefit maximum reached. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: patient has reached the lifetime dollar limit for covered benefits under their plan; Patient has used the maximum number of allowed visits or services for a particular benefit; Pre-ACA grandfathered plans may still have lifetime dollar limits. The group code paired with CARC 35 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

Cause Frequency
Patient responsible after maximum All services beyond the lifetime maximum become patient responsibility Most Common

How to Resolve

  1. Verify the adjusted amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the adjustment amount was applied correctly per plan terms.
  2. Confirm plan benefit details Use the payer portal or eligibility tool to verify the patient's current benefit status and confirm the adjustment aligns with plan terms.
  3. Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the adjustment amount, and the balance the patient owes.
  4. Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
  5. Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
Appeal Guide

If the plan should not have lifetime limits under ACA, appeal on the patient's behalf. Otherwise, the patient is responsible for charges beyond the legitimate lifetime maximum.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-35:

RARC Description
N381 Consult contract/fee schedule for payment information Review lifetime maximum details before billing patient →

How to Prevent PR-35

Also Filed As

The same CARC 35 may appear with different Group Codes:

CO-35 OA-35

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-40 — Charges Do Not Meet Emergent/Urgent Care Qualifications PR-49 — Non-Covered Routine/Preventive Exam PR-51 — Non-Covered Pre-existing Condition PR-55 — Procedure/Treatment Deemed Experimental/Investigational

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://revenuecyclemgmt.com/claim-adjustment-reason-codes/
  3. https://www.rivethealth.com/blog/carcs-rarcs-claim-adjustment-remittance-advice-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.